Purpose: Multiple myeloma and solid tumor metastases can cause bone disease leading to skeletal-related events (SREs) such as bone pain, fractures, and spinal cord compression. Intravenous bisphosphonate therapy—which is indicated in such cases—can lead to osteonecrosis of the jaw and hypocalcemia further putting patients at risk for SREs. These risks can be avoided by dental evaluation before bisphosphonate therapy and calcium and vitamin D supplementation throughout treatment. Our study of veterans treated with bisphosphonates for bone metastases or multiple myeloma aimed to (1) assess screening dental evaluation prior to treatment; and (2) measure effectiveness of calcium and vitamin D supplementation.
Methods: We performed a retrospective chart review at the James J. Peters VAMC of 117 veterans with multiple myeloma or bone metastases who received intravenous bisphosphonate therapy between January 2008 and November 2013. Those receiving bisphosphonates for other morbidities such as osteoporosis or hypercalcemia were excluded. Those getting dental clearance before intravenous bisphosphonate therapy and supplementation of vitamin D and calcium were assessed. Charts were further reviewed to gather outcomes data on incidence of osteonecrosis of the jaw and SREs such as bone pain, pathologic and traumatic fractures, orthopedic surgery, spine or nerve root compression. These data were analyzed using descriptive statistics to calculate frequencies, mean/median, and proportions. Odds ratios were calculated to assess differences in SRE outcomes for those who received supplementation as compared to those who did not get supplementation with calcium and vitamin D.
Results: Of the 117 patients included in the study, 97% were males aged from 58 to 92 years. Of these, 55 (47%) had prostate cancer, 21 (17%) had multiple myeloma, and 16 (14%) had lung cancer. All patients receiving bisphosphonates for bone metastases had undergone a dental evaluation prior to starting therapy; none were reported to have osteonecrosis of the jaw. However, only 78% had vitamin D levels checked before therapy; 69% of these were vitamin D deficient and received vitamin D supplementation. Overall, rates of calcium and vitamin D supplementation were very low (34% and 41%, respectively). Fifty-four percent of the patients reported an SRE; 49% with bone pain, 13% with pathological fractures, 7% with traumatic fractures, and 8% with nerve root compression. Vitamin D supplementation significantly reduced the odds of an SRE for our patients (OR 0.37, 95% CI = 0.19- 0.74, P < .05).
Conclusions: Onset of SREs can be reduced or delayed with bisphosphonates; however, patients need prior screening for osteonecrosis of the jaw and optimized calcium and vitamin D levels. Our study showed that although screening for osteonecrosis of the jaw was at optimum levels, supplementation with calcium and vitamin D was lacking in patients on bisphosphonates. In our study, vitamin D supplementation reduced the risk of an SRE by 63%. Hence, adequate prevention with vitamin D supplementation can improve bone health among veterans with multiple myeloma or bone metastases. Data-based policies and practices need to be incorporated to provide care to ensure adequate bone health.